Bioabsorbable clips and applicator for tissue closure

ABSTRACT

Surgical clips and surgical applicators used in performing rapid tissue closure in either minimally invasive surgeries or traditional open procedures are provided. In one example approach, a surgical clip comprises opposing sides extending from a top portion and terminating at tips positioned below the top portion. The resting position of the clip is its closed position, and in the closed position, the tips are set at a first distance apart. Each side has a cut-out (or hole or aperture) opposite one another. Each cut-out is fully surrounded by the side and does not extend to the top or tips. Each cut-out is configured to engage an inwardly turned hook at the end of a clip array or clip applicator such that the sides bend outwardly away from each other when pressure is applied on the top portion of the clip, thereby placing the clip in an open position.

CROSS REFERENCE TO RELATED APPLICATIONS

The present application is a continuation of U.S. patent applicationSer. No. 14/486,649, filed Sep. 15, 2014, entitled “BIOABSORBABLESTAPLES AND APPLICATOR FOR TISSUE CLOSURE. U.S. patent application Ser.No. 14/486,649 claims priority to U.S. Provisional Patent ApplicationNo. 61/878,298, filed Sep. 16, 2013, entitled “BIOABSORBABLE STAPLES ANDAPPLICATOR FOR TISSUE CLOSURE,” the entire disclosures of which arehereby incorporated by reference in their entirety.

STATEMENT OF GOVERNMENT SUPPORT

This invention was made with government support under TR000128 awardedby the National Institutes of Health. The government has certain rightsin the invention.

FIELD

The present disclosure relates to surgical clips and surgical clipapplicators used in tissue closure.

BACKGROUND

The brain and spine are covered with a tough outer membrane called thedura mater, or dura. During surgical procedures, e.g., spinal surgery,the dura mater may be opened intentionally or inadvertently. Such anopening is called a durotomy or dural tear. Dural tears requiringclosure or repair have been reported to occur in a significantpercentage of surgical procedures. In some approaches, sutures are usedto repair or close the dura. Durotomies must be closed prior to closingthe skin. Failure of the closure can result in persistent cerebrospinalfluid (CSF) leakage, for example. This leakage may result in woundbreakdown, spinal headaches, infection, meningitis, and otherconsequences.

Minimally invasive surgeries (MIS) are becoming more commonly usedduring surgical procedures, e.g., to treat a variety of pathologiesincluding herniated discs, spinal stenosis, synovial cysts,spondylolisthesis, deformity, intradural tumors, etc. Such proceduresuse smaller incisions to decrease intraoperative blood loss, reducetissue disruption, decrease postoperative pain, and decrease lengths ofhospital stays, for example.

Minimally invasive surgeries make use of smaller ports and result inless tissue disruption than traditional procedures. However, should adurotomy occur using a minimally invasive surgery, closure of thatdurotomy can become extremely difficult or impossible due to the smallsize of the incision. For example, in the setting of minimally invasivespine surgery, the ability to close a durotomy may be compromised whensuture material cannot be manipulated sufficiently to achieve tightclosure. Thus, due to the physical limitations of small working areas,repair of a durotomy may be technically difficult and time-consumingwhen using conventional suture and knot-tying techniques.

In order to overcome these technical difficulties resulting fromminimally invasive surgeries, metal clips or staples, such as titaniumclips, delivered via a suitable applicator may be crimped or bent froman open position into a closed position around the tissue edges to closea hole in a tissue such as a durotomy. However, in such approaches, itis necessary to place the clips close together along a dura tear inorder to close the tissue since such clips may too thin to cover andhold significant lengths along the tissue break. Further, use of metalclips or staples either results in a permanent foreign body left in thetissue or a second surgical intervention to remove the staples. Staplesleft in the tissue interfere with postoperative imaging since metalclips result in undesirable artifacts in radiographic imaging such asmagnetic resonance imaging (MRI) and computed tomography (CT) scans.

SUMMARY

The present disclosure is directed to surgical clips and surgicalapplicators that may be used in performing rapid tissue closure ineither minimally invasive surgeries or traditional open procedures. Inparticular, the surgical clips described herein are intended for use inclosing durotomies, particularly durotomies resulting from minimallyinvasive surgeries.

A surgical applicator is used to deliver the clips down a small opening,thereby obviating the need for sutures and knot tying to close thedurotomy. An array of stacked surgical clips is to be loaded into achamber or reservoir of the surgical applicator. A force is applied tothe center of the top of a clip located at a tip of the surgicalapplicator. The sides of that clip are held at the tip of the applicatorsuch that the mouth of the clip opens around the everted tissue edges ofthe dura. Upon release of the clip from the applicator, the clip graspsthe everted edges, pulling the edges towards one another, closing thetear in the tissue. The push rod can then engage the next clip in thearray so that the next clip is pushed into position to be opened at themouth of the applicator for a subsequent application.

Since everted tissue edges are grasped by the surgical clip in such anapproach, a risk of adhesion to the underlying spinal cord may bepotentially reduced. Further, by applying a force to open such asurgical clip from a closed, resting state to an intermediate open stateand then releasing the force to permit the clip to close to its restingstate around the dural tissues, a greater amount of control may beconferred to the final closed state of the clip around the tissues toprovide pressure on the dura leaflets for maintaining closure of thedurotomy.

In this way, closure of the dura using a small bioabsorbable clip tograsp but not penetrate the tissue edges and maintain tension until thetissues heal may be applied quickly, easily, and in rapid succession byusing an applicator. Such an approach may potentially increase speed andease of clip application, decrease the risk of CSF leakage, decreaseintradural adhesions due to non-penetration of the clip, reduce risk ofadhesion to the underlying spinal cord, minimize dural exposure, anddecrease expensive operative time. Further, such an approach may also beused in other surgical arenas where reapproximation is desired;including, for example, cranial surgery for closure of the dura, generalsurgery for closure of hollow organs, urologic surgery for closure ofthe bladder, closure of uereters and other tubular structures, andgynecological procedures for closure of reproductive structures.

Disclosed herein is a surgical clip that includes opposing sidesextending from a top portion. The opposing sides terminate at tipspositioned below the top portion. The resting position of the clip isits closed position, and in the closed position, the tips are set at afirst distance apart. Each side has a cut-out (or hole or aperture)opposite one another. Each cut-out is fully surrounded by the side anddoes not extend to the top or tips. Each cut-out is configured to engagean inwardly turned hook at the end of a clip array or clip applicatorsuch that the sides bend outwardly away from each other when pressure isapplied on the top portion of the clip, thereby placing the clip in anopen position. In the open position, the distance between the tips isgreater than the distance between the tips in the open position. Inaddition, the width of the clip is at least 25% of the length of theclip (length is the dimension from the end of the first side to the endof the second side, while width is the dimension of the clipperpendicular to the length). Each tip is made up of at least twopoints. Each point converges to a point towards the opposing point onthe other side to form a barb-like feature.

In additional examples, the top portion can be flat or concave and/ormay include a cut-out or aperature. The sides can be straight, flat, orconvex. The sides can also comprise a flat portion coupled to the topportion by a curved top junction and coupled to the tip via a curvedbottom junction. In this case, the flat portion can be perpendicular tothe top portion in the closed position and at an angle greater than 90°in the open position. In still more examples, the clip may be made of abioabsorbable and/or radiolucent material. Alternatively, the height ofthe clip may be less than the width and length of the clip.

Disclosed herein is an array of surgical clips. The array comprises twoor more of the clips described above and a chamber housing the clips.The chamber is small enough to maintain the sides of all the clipsoriented in the same direction, but large enough to allow movement ofthe clips in the direction of the tips of the clips. The clips arevertically stacked along a central axis extending through the center ofthe top portion and a center midpoint between the first and second tipsof each clip. The clips in the array can also be in physical contactwith one another.

Disclosed herein is a surgical clip applicator. The applicator includesa clip array as described above that has a chamber with an open end,inwardly facing hooks distal to the top clip in the array, and a pushrod configured to apply pressure to the top clip in the array. The hookscan be coupled to the open end of the chamber. Alternatively, the hookscan be coupled to the body of the applicator. The applicator can alsohave a transparent view window in a wall of the chamber. The view windowextends from the open end of the chamber. The distance is such that allthe clips in the chamber can be visualized. The view window isperpendicular to the opposing interior walls of the chamber.

It should be understood that the summary above is provided to introducein simplified form a selection of concepts that are further described inthe detailed description. It is not meant to identify key or essentialfeatures of the disclosed subject matter, the scope of which is defineduniquely by the claims that follow the detailed description.Furthermore, the disclosed subject matter is not limited toimplementations that solve any disadvantages noted above or in any partof this disclosure.

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS

FIG. 1 shows an illustration of a surgical applicator applying examplesurgical clips to close a durotomy.

FIGS. 2A-12F show scaled drawings of example surgical clips and examplesurgical clip applicators in accordance with the disclosure.

DETAILED DESCRIPTION

The following description relates to bioabsorbable surgical clips andsurgical applicators for performing rapid watertight tissue closure inminimally invasive or traditional open procedures. For example, asillustrated in FIG. 1, a surgical applicator 116 may be used to deliverone or more surgical clips, e.g., clips 118, to assist in tissueclosure. In FIG. 1, a dural tear or durotomy 108 is shown in the duramater 104 around a spinal cord 106. As remarked above, the dura mater isa tough outer membrane covering the brain and spinal cord which may beopened intentionally or inadvertently during surgical procedures. Theclips disclosed herein can be interchangeably referred to as staples andvice versa.

The surgical clips may be composed of any material including anysuitable bioabsorbable or resorbable material. The terms bioabsorbableand resorbable are used herein to mean dissolving inside the human bodyafter a period of time. In some examples, the bioabsorbable material maybe chosen based on a time duration at which the material dissolves. Forexample, the bioabsorbable material may have the property that it doesnot substantially dissolve within seven days after installation alongthe tissue but dissolves anytime after one week while maintainingstructural integrity before then. For example, the bioabsorbablematerial may comprise a biocompatible, bioabsorbable polymer such asPoly-L-Lactic Acid/Poly glycolic acid (PLLA/PGA), Polycapralactone, orsome combination thereof By using a bioabsorbable material, no permanentforeign body is left in the tissue following surgery. Further in someexamples, the clip may be composed of a material that is radiolucent,e.g., invisible or transparent to x-rays, as well as bioabsorbable. Forexample, the surgical clips may be composed of a suitable material whichis radiolucent and bioabsorbable so that substantially no undesirableartifacts from the clips appear in radiographic imaging e.g., inmagnetic resonance imaging (MRI) and computed tomography scans (CT).Further, by using a bioabsorbable and radiolucent material, surgicalclips with a wide footprint may be used to cover a greater length alongthe tissue thereby potentially decreasing a number of clips needed toreliably seal the tissue in a water tight fashion.

As illustrated in FIG. 1 at 124, a surgical clip used to close adurotomy may comprise a first side 132 and a second side 130, where thesecond side 130 opposes the first side 132. The first and secondopposing sides 132 and 130 extend from a top portion 128 of the clip andterminate at first and second tips positioned below the top portion 128.For example, the first side 132 is coupled to and extends from topportion 128 and terminates at a first tip 134 positioned below the topportion 128. Likewise, the second side 130 is coupled to and extendsfrom top portion 128 and terminates at a second tip 136 positioned belowthe top portion 128. In an installed, closed position, the tips 134 and136 of the surgical clip grasp but do not penetrate or pierce evertedtissue edges. For example, in FIG. 1 surgical clip 114 is shown in aninstalled position along the durotomy 108 grasping everted tissue edges112 and 110. The surgical clips may include a variety of features andmay have a variety of shapes and dimensions, examples of which aredescribed below with reference to the scaled drawings of FIGS. 2A-12F.For example, the clip may have a length in a range from 3-5 millimeters(mm), a height in a range of 3-5 mm, a width in a range of 3-5 mm, and adiameter (if cylindrically shaped) in a range of 3-5 mm. In someexamples, the top portion 128 of the clip may include an aperture 138,slots, and/or other features used to achieve a particular bending momentof the surgical clip. For example, as described in more detail below,sides of the surgical clip may be temporarily bent outward by applying aforce to the top portion of the clip while holding the sides in place toinstall the clip over everted tissue edges. A size of a slot or apertureor a thickness of the top portion of the clip may be adjusted so thatthe clip confers an optimal amount of force to grasp the tissue whilemaintaining the ability to be temporarily opened via engagement withfeatures on an end of the surgical applicator during an installation ofthe clip. For example, the clip may be designed to withstand at least 10cmH₂O pressure (e.g., prostrate pressure) without leakage and may, insome examples, be designed to withstand 20 cmH₂O (e.g., standing lumbarpressure) without leakage. Further, the material selected may be basedon a desired elasticity for applying a predetermined holding force tothe tissue for a predetermined duration following installation of theclip around everted tissue edges.

The clip may include features which are configured to engage with thesurgical applicator to assist in installation of the clip around edgesof a tissue break. For example, the surgical clip may include cut-outs,notches, tabs or other suitable features which engage protrusions at atip of the surgical applicator, e.g., which engage protrusions 122 and123 of surgical applicator 116 shown in FIG. 1. The example clips shownin FIG. 1 include tabs extending outwardly from the first and secondsides of the clip. For example, a tab 140 is shown extending outwardlyfrom first side 132 and may be configured to engage with protrusion 123of the applicator 116 and tab 142 is shown extending outwardly fromsecond side 130 and may be configured to engage protrusion 122 of theapplicator. However, in other examples, such tabs may be omitted orother alternative engagement features may be included on the opposingsides of the clip. In some examples, the opposing ends of the clip mayinclude locking features which assist in holding the clip in a closedposition after an installation of the surgical clip around evertedtissue edges. For example, a barb or other suitable feature may beincluded on the clip extending inwardly from a first side of the clipwhere an end of the barb is configured to engage with an apertureincluded in a second side of the clip opposing the first side.

As illustrated in FIG. 1, a stack of surgical clips 118 may be loadedinto the surgical applicator 116 for quick successive delivery ofsurgical clips to grasp everted tissue edges, e.g., the bent andinterfacing tissue edges 112 and 110, to close the durotomy. Forexample, as shown in FIG. 1, an installed surgical clip 114 grasps butdoes not penetrate or pierce the everted edges of the dura therebyholding the edges together. Surgical applicator 116 may be used todeliver the clips down a small opening during minimally invasiveprocedures thereby potentially obviating the need for sutures and knottying to close the dura. In one example approach, an array of stackedsurgical clips 118 may be loaded into a chamber or reservoir of thesurgical applicator and a downward force from a push rod in the chambermay be used to push the center of a clip located at a tip of thesurgical applicator, e.g., clip 120 shown in FIG. 1, while the sides ofthat clip are firmly held at the tip causing the mouth of the clip toopen around the everted tissue edges 110 and 112 of the dura. To releasethe clip, the center push rod may be retracted allowing the clip tograsp and reapproximate the two dural edges 110 and 112. The center pushrod can then retract further to engage the next clip in the reservoir sothat the next clip is pushed into position to be opened at the mouth ofthe applicator for a subsequent application to the everted tissue edges.It should be understood that the use of a push rod to eject the clip isexemplary in nature and that any other suitable pusher or ejectorfeature may be included in the clip applicator. Further, the term “pushrod” as used herein may refer to any such suitable pusher or ejectorfeature of the applicator used to deploy the clips.

The surgical clips have a closed resting configuration which can besubstantially the same before and after installation along the tissueedges. During installation with the surgical applicator, the surgicalclips have an intermediate open state formed by engagement of the clipwith a tip of the surgical applicator during the installation of theclip. By applying a force to the top of the clip while sides of the clipare engaged with the tip of the surgical applicator, a reversibledeformation of the clip from a closed resting position to anintermediate open position may occur. This deformation is recoverableupon removal of the force applied to the top of the clip after the clipis positioned around the tissue edges so that the clip returns to itsclosed resting position to grasp the everted edges when the force isremoved from the clip.

FIG. 1 shows an example clip in a closed resting state at 124 and in theintermediate open state at 126. In the closed resting state there is afirst distance 146 between the first and second tips 134 and 136. Inthis closed position, the first distance may chosen so as to provide asufficient amount of space between the tips 134 and 136 to accommodate athickness of the everted tissue edges to which it is to be applied(e.g., enough space to accommodate twice the thickness of the dura)while maintaining sufficient gripping force on the everted tissue edgesafter application. The first side 132 and the second side 130 of theclip are configured to engage the clip applicator such that, when theclip applicator is used to apply downward pressure to the top portion128 of the clip, the first and second sides bend outwardly away fromeach other thereby increasing the distance between the tips to a seconddistance 148 greater than the first distance 146 so that the clip istemporarily deformed to an open position for installation around thetissue edges. In some examples, this second distance 148 may be apredetermined distance, e.g., at least 3 mm, achieved via forces appliedto the clip from the clip applicator.

By applying a force to open such a surgical clip from a closed, restingstate to an intermediate open state and then releasing the force topermit the clip to again close to its resting state around the duraltissues, a greater amount of control may be conferred to the finalclosed state of the clip around the tissues to provide an optimalpressure on the dura leaflets for maintaining closure. For example, thegrasping force of the closed resting state of such a clip may betailored to a specific type or thickness of tissue to which it is to beapplied.

FIGS. 2A-12F described below show scaled drawings of various exampleembodiments of surgical clips and surgical clip applicators. Each of thedrawings shown in FIGS. 2A-12F is drawn to scale and the examplenumerical dimensions shown in these figures are in millimeters (mm)Further, like numbers used throughout the figures correspond to likeelements.

Turning to FIGS. 2A-4F, a first example embodiment of a surgicalapplicator 116 and surgical clip 124 is shown from various perspectivesand cross-sections. At 206, 208, 210, and 212 in FIG. 2A variousviewpoints of the first example embodiment of a surgical clip 124 areshown. In particular, a front face view of an example clip 124 is shownat 206, a side view of clip 124 is shown at 208, a bottom view of clip124 is shown at 210, and a perspective view of clip 124 is shown at 212.

Clip 124 comprises a concave top portion 128 with opposing roundedconvex sides 130 and 132 extending therefrom. In particular, a firstside 132 is coupled to top portion 128 via a rounded junction 251 andcurves inwardly from junction 251 to a tip 134 positioned below topportion 128. Likewise, a second side 130 is coupled to top portion 128via a rounded junction 252 and curves inwardly from junction 252 to atip 136 positioned below top portion 128. A thickness of each tip of theopposing tips 136 and 134 tapers or decreases in a direction toward theopposing tip so that each tip of the opposing tips 136 and 134 convergesto a point in a direction towards the opposing tip. The concave topportion 128 curves toward the interior of the clip in the center of thetop portion so that a minimum height of the clip occurs at the center ofthe top portion. The convex opposing sides 130 and 132 and the roundedjunctions 251 and 252 coupling the sides 132 and 130 to the top portionform a heart-shaped face as seen in view 206 wherein each opposing sideforms opposing “C-shapes” which are coupled together via the concave topportion 128.

Each of the first and second tips 134 and 136 converges to a point in adirection towards the opposing tip. For example tip 134 is comprised ofa first point 260 and a point 262 and tip 136 comprises a first point259 and a second point 261. Each point of a tip converges in thicknessand width to a point facing an opposing tooth on the other tip. Forexample, a width and thickness of tooth 260 on tip 134 decreases in adirection toward the opposing tooth 259 on tip 136 and a width andthickness of tooth 262 on tip 134 decreases in a direction toward theopposing tooth 261 on tip 136. Teeth 259 and 261 on tip 136 likewiseconverge to the opposing teeth on tip 134 so that an aperture 263 isformed in the bottom of the clip between teeth of the tips. In someexamples, this aperture 263 may have a circular shape with apredetermined diameter, e.g., a diameter of 2.5 mm. However, it shouldbe understood that the aperture formed between the teeth of the tips onthe bottom of the clip may have any suitable diameter or shape, e.g.,oval, rectangular, etc. The points may be used to hold everted edges oftissue in place while not penetrating and not piercing the tissue whenrepairing a durotomy, for example. One of skill in the art in light ofthis disclosure would understand how to make tips 134 and 136 ofsufficient sharpness to grasp but not penetrate or pierce everted edgesof a tissue such as a dura without undue experimentation.

Example clip 124 further includes cut-outs in each opposing side of theclip for engagement with opposing protrusions 122 and 123 at a distalend 247 of the clip applicator 116. For example, first side 132 includesa cut-out 255 forming a rectangular aperture or hole within a center ofthe first side 132. Likewise, second side 130 includes a cut-out 256forming a rectangular aperture or hole in the center of the second side130. These cut-outs in the sides of the clip may be sized and shaped sothat the opposing protrusions 123 and 122 at the end 247 of theapplicator lock the clip in place at the end of the applicator asexemplified with clip 120 at 204 in FIG. 2C.

The example clip 124 has a height 254 extending in a direction from amidpoint of the opposing tips 134 and 136 towards the top portion 128, alength 253 extending in a direction from first side 132 towards secondside 130, and a width 299 extending from a front of the clip towards theback of the clip in a direction perpendicular to length 153. In thisexample, the height 254 is less than the length 253 and the height issubstantially the same as the width 299. For example, the length may beapproximately 5 mm and the height and width may both be approximately 3mm; however, it should be understood that these dimensions are providedas examples and any suitable height, length, and width may be used. Thecut-outs 255 and 256 may be located in a center of the sides of the clipand may have a width 257 of approximately 1 mm along a direction ofwidth 299 and may be offset from the face of the clip by an amount 258which may be approximately 1 mm, for example. Again, it should beunderstood that these dimensions are provided as examples and anysuitable dimensions for the cut-outs may be used.

The surgical clip 124 is shown in views 206, 208, 210, and 212 in FIG.2A in a closed resting position with a first distance 146 betweenopposing tips 134 and 136. For example, this first distance 146 betweenthe tips may be approximately 0.05 mm when the clip is in its restingclosed state. A length of this first distance 146 may be based on a typeand thickness of tissue to which it is to be applied. For example, thefirst distance 146 may be greater for applications on a thicker tissue.

Though not shown in FIG. 2A, in some examples, the top portion 128 maybe substantially flat when the clip is in the resting state (e.g., asshown in FIG. 1), but may become concave or temporarily bent inwardduring a transitional intermediate open state of the clip duringinstallation of the clip using clip applicator 116. In particular,protrusions 123 and 122 of clip applicator 116 may engage cut-outs 255and 256 when the clip is positioned at the distal end 247 of theapplicator to hold the clip in place while a force is applied to the topof the clip so that the distance between the tips of the clip increaseto a second distance greater than the first distance 146, e.g., greaterthan 0.05 mm, so that the tips of the clip are opened for installationof the clip around everted tissue edges. This second distance may be adistance of at least a predetermined amount, e.g., at least 3 mm.

Various views and cross-sections of an example surgical applicator areshown at 202, 204, 214, 216, 218, 220, 222, and 224 in FIGS. 2A-3E. Inparticular, at 202, a perspective view of example surgical clipapplicator 116 is shown. At 204, a detailed view is shown of a distalend 247 of the applicator 116 at the region F shown in view 202. Theview 204 is shown at a scale of 4:1 relative to the view shown at 202.At 214 a front view of applicator 116 is shown. At 216, a detailed viewis shown of cross-section A-A shown in view 214. View 218 shows adetailed view of the cross-section A-A of the region B shown in view216, where view 218 is shown at a scale of 4:1 relative to view 216.View 220 shows a side view of applicator 116. View 222 shows across-sectional view along cross-section C-C from view 220. View 224shows a detailed view of region D shown in view 222 and is shown at ascale of 4:1 relative to view 222. Further, the views 206, 208, 210, and212 of clip 124 are drawn at a scale of 8:1 relative to view 202 ofapplicator 116.

With reference to views 202, 204, 214, 216, 218, 220, 222, and 224 shownin FIGS. 2A-3E, the surgical applicator 116 comprises an elongated body241 defining a chamber with an open end 247 within which a push rod 243is contained. The push rod 243 extends away from the open end 247 of thesurgical clip applicator and terminates at a thumb pusher element 250.The thumb pusher element 250 comprises a curved handle shaped to fit athumb of a user. The clip applicator further includes two opposingfinger grasping elements 248 and 249 coupled to the elongated body 241.For example, a user may grip the finger grasping elements 248 and 249with two fingers and apply a downward force to the thumb pusher element250 to urge the push rod downward toward the distal end 247 in order toapply a force to one or more clips in the chamber of the applicator.

An array or stack of surgical clips 118 is included within a chamber orreservoir within the walls of the elongated body 241 of the applicator.In the array of stacked clips 118, the stacked surgical clips arevertically stacked along a central axis extending through a center ofthe top portions and a center midpoint between the first and second tipsof each surgical clip in the array and the first and second opposingsides of each clip are orientated in the same direction as the first andsecond opposing sides of the other clips in the plurality of stackedsurgical clips.

In some examples, the array of stacked clips may be loaded into thechamber of the surgical applicator as a group rather than individually.For example, a user may obtain a package of a predetermined number ofpre-stacked and pre-aligned surgical clips, e.g., including five or moreindividual clips stacked one on top of the other and oriented in thesame direction, and may load this package of clips into the surgicalapplicator, e.g., via an entry point comprising an opening at a top endof the applicator when the push rod 243 is removed from the chamber. Asanother example, an array of surgical clips may be preloaded into theapplicator so that an end user receives a fully assembled pre-packagedapplicator including a pre-loaded quantity of clips loaded within thechamber. Such a pre-packaged surgical clip applicator may have anysuitable number of clips contained therein, e.g., 5, 10, 15, or 30 clipsper applicator. The number of clips included in an applicator may dependon a particular surgical application. Though five clips are shown in thearray of stacked clips in the figures, any suitable number of clips maybe included in a clip array. For example, the number of clips includedin a clip array may depend on a particular surgical application or alength of the tissue tear to which the clips are to be applied. Such apre-packaged pre-loaded surgical clip applicator may be sterilized andsuitably wrapped and, in some examples, may be disposable after use andmay include labeling which indicates various parameters associated withthe surgical applicator and clips therein such as dimensionalinformation, disclaimer information, clip material composition, etc.

Different sizes of the applicator may be available depending on aquantity of clips desired (e.g., an applicator may house 5-30 clips).For example, the applicator may come in different lengths depending ontype of surgery to be performed and the tissue on which the surgery willbe performed. A short handle applicator may be used for open surgerieswhile a longer handle applicator may be used for deeper, smaller portalsgenerated by minimally invasive surgical procedures. For example aheight 242 of the applicator 116 may be in a range of 125-150 mm (˜5-6inches) for minimally invasive procedures. The applicator may be used byright or left-handed male and female neurosurgeons and may utilizeactivation mechanisms that are standard or familiar to neurosurgeons.For example, the activation mechanism of the applicator may utilize apistol grip design, a syringe plunger-type design, a looped-end forcepdesign, etc. Further, the applicator may be activated by fingers of auser rather than whole-hand activation for increased dexterity and finemotor control.

The array of stacked clips includes a top clip 237 which is in contactwith an end of the push rod 243 opposing the thumb pushing element 250within the chamber of the applicator, and a bottom clip 120 which atleast partially protrudes from the distal end 247 of the applicator. Thebottom clip 120 may be held in position via engagement of the cut-outsin the sides of the clip with the opposing protrusions 123 and 122 atthe distal end 247 of the applicator. The array of stacked clips is heldin a non-rotatable position via inner walls of the chamber of theapplicator. For example, opposing walls 238 and 239 may abut the alignedopposing sides of each clip in the array of clips 118 so that the clipsare positioned to engage protrusions 122 and 123 at the end of theapplicator for opening the clips from their closed resting states tointermediate opened states for installation around everted tissue edgesas described above with regard to FIG. 1.

In some examples, a substantially transparent view window 240 may beincluded along a portion of at least one wall of the chamber of thesurgical applicator. The transparent view window 240 may comprise atleast a portion of a wall of the applicator chamber perpendicular toside walls 238 and 239 of the chamber. For example, the view window mayextend a distance along a wall of the chamber from the distal end 247 ofthe applicator, where said distance is greater than a height of theplurality of stacked surgical clips and wherein the transparent viewwindow is perpendicular to opposing side walls 238 and 239 of thechamber. A back wall 270 opposing the transparent window 240 and alsoperpendicular to side walls 238 and 239 may abut aligned faces of theclips along a back side of the array of stacked clips 118. Further, aninner surface of the view window 240 may abut aligned faces of the clipsalong a front side of the array of stacked clips 118. The transparentview window may assist a user in operation of the applicator. Forexample, the view window may permit a user to determine whether or not asufficient number of clips are loaded in the applicator, how many clipsremain loaded in the chamber, and positional information of the clips inthe applicator.

In this example embodiment, the push rod 243 interfaces with a topportion of top clip 237 via a clip interfacing element 245 coupled to anend of the push rod 243 opposing the thumb pusher element 250. Further,in this example, a spring element 246 is included around a portion ofthe push rod between the pusher element 245 and an inner wall feature221 within the chamber of the applicator. The spring element 246 cancomprise a wire spring encircling a portion of the push rod whichprovides a biasing force to the push rod 243 in a direction away fromthe distal end 247 in order to return the push rod to an initialretracted position following an application of a downward force to thepush rod via the thumb pushing element. However, in other examples,e.g., as described below, such a spring element may be omitted.

When the bottom clip 120 is pushed via the push rod 243 towards the openend 247 of the applicator, the opposing protrusions 123 and 122 of theapplicator housing snap into the cut-outs in the sides of the bottomclip forcing the clip to retract and be held in place at the open end ofthe applicator. When a subsequent force is applied to the top portion oftop clip 237 in array 118, the force is transferred through the array ofclips to the top portion of bottom clip 120 which causes the opposingsides of the bottom clip to bend outwardly away from each other, therebyincreasing the distance between the tips of the bottom clip to place theclip in an open position. While in this intermediate open position, thebottom clip may be positioned to encompass the tissue edges and pushedforward onto the tissue edges so that the opposing protrusions of theapplicator disengage the cut-outs in the sides of the bottom clip as theclip is pushed out of the end of the applicator so that the clip returnsto its closed resting state with the opposing tips engaging the evertedtissue edges. In some examples, a clicking mechanism may be used todeploy a surgical clip. For example, a “click” may be performed byapplying an initial force to push rod 243 to load the clip into theopposing protrusions 122 and 123 extending from end 247 of applicator116. Deployment of the loaded clip may then be performed by a second“click” wherein the handle/trigger 250 is squeezed to apply a secondforce to the push rod 243 to cause the clip to protrude from the end ofapplicator in the expanded open position around everted tissue edgesuntil it releases or locks into place around the tissue edges.

FIGS. 4A-4F show various viewpoints and cross-sections of an examplesurgical clip applicator system 402 which comprises a tubular retractor297 within which clip applicator 116 may be inserted while performing asurgical procedure on dura 104. At 226, a top view of the surgical clipapplicator system is shown. At 228, a side view of the surgical clipapplicator system is shown. At 232, a detailed view of an end of thetubular retractor 297 is show for the region E shown in view 228. At230, a perspective view of the surgical clip applicator system with theapplicator inserted into the tubular retractor 297 at an angle is shown.At 234, a side view of the surgical clip applicator system with theapplicator inserted into the tubular retractor 297 at an angle is shown.View 236 shows a detailed view of the region G shown in view 234.

Tubular retractor 297 may comprise a cylindrical body 283 defining aninner working aperture 281 extending from a top lip 280 to an open end298 at the surgical site. The top lip extends around a circumference ofthe working aperture at a top open end of the tubular retractor 297opposing the open end 298 and a circumference of the top lip may begreater than a circumference of the cylindrical body. For example, theinner working aperture may have a diameter of approximately 25 mm andmay have a height 296 of approximately 90 mm so that applicator 116 caneasily fit within the tubular retractor during a surgical procedure.

The tubular retractor 297 may further include a supporting element 282coupled to the lip 180 at an end of the tubular retractor 297 opposingend 298. For example, during a surgical procedure, the tubular retractor297 may be positioned via supporting element 282 so that end 298encompasses a surgical working area over the tissues to be repaired. Inorder to close the tissue using the clip applicator, the applicator 116may be inserted into the tubular retractor 297 so that the distal end247 of the applicator extends beyond end 298 of the tubular retractor297 toward the tissue tear so that a surgical clip may be applied toeverted tissue edges along the tear.

As shown in view 234 the applicator may be tilted away from a centralaxis of the tubular retractor 297 so that an angle 290 is formed betweena central axis of the applicator and a central axis 291 of the tubularretractor 297, e.g., a 5° angle. In this way a clip may be applied usingthe applicator without obstructing the view of the surgeon applying theclips to the tissues.

Turning to FIGS. 5A-6F, a second example embodiment of a surgicalapplicator 116 and surgical clip 124 is shown from various perspectivesand cross-sections. At 506, 508, 510, and 512 various viewpoints of thesecond example embodiment of a surgical clip 124 are shown. Inparticular, a front face view of an example clip 124 is shown at 506, aside view of clip 124 is shown at 508, a bottom view of clip 124 isshown at 510, and a perspective view of clip 124 is shown at 512. Thesurgical clip shown in FIG. 5A is similar to the surgical clip shown inFIG. 2A. However, in this example, a thickness of the walls of the clipvaries throughout a length of the top portion 128 of the clip. Forexample, as shown in view 506, a thickness of the clip wall throughoutthe concave top portion 128 is less than a thickness of the clip wallthroughout the opposing sides 132 and 130. By making the top portionthinner, an elasticity of the clip may be increased so that a reducedamount of force is needed to cause the opposing sides of the clip tobend outwardly during installation of the clip with applicator 116.

Various views and cross-sections of the second example surgicalapplicator are shown at 502, 504, 514, 516, 518, 520, 522, and 524 inFIGS. 5B-6F. In particular, at 502, a perspective view of examplesurgical clip applicator 116 is shown. At 504, a detailed view is shownof a distal end 247 of the applicator 116 at the region A shown in view502. The view 504 is shown at a scale of 4:1 relative to the view shownat 502. At 514 a front view of applicator 116 is shown. At 516, adetailed view is shown of cross-section B-B shown in view 514. View 518shows a detailed view of the region C shown in view 516, where view 518is shown at a scale of 4:1 relative to view 516. View 520 shows a sideview of applicator 116. View 522 shows a cross-sectional view alongcross-section D-D from view 520. View 524 shows a detailed view ofregion E shown in view 522 and is shown at a scale of 4:1 relative toview 522. Further, the views 506, 508, 510, and 512 of clip 124 aredrawn at a scale of 8:1 relative to view 502 of applicator 116.

In this example, the push rod 243 can but need not include a springelement but instead interfaces with a top clip 237 in a stacked array ofclips 118 loaded in the chamber of the applicator 116 via a pushingelement 502 coupled to an end of the push rod 243 opposing the thumbpusher element. The pushing element 502 comprises an extension coupledto the push rod with a diameter and circumference less than the diameterand circumference of the push rod 243 and is held in position within thechamber of the applicator via walls 551 of the applicator. As shown inview 522, a reservoir 552 adjacent to distal end 247 is included in thechamber between the walls 551 which hold the push rod in position andthe distal end 247. A thickness of walls 553 defining the reservoir 552is less than the thickness of the walls 551 which hold the push rod 243in position. In this example, the transparent view window 240 extendsfrom the distal end 247 to form a wall of the reservoir 552 andterminates at a transition wall 504 wherein the width of the applicatorincreases in a direction from the distal end 247 towards the thickerwalls 551. In this example, the height of the applicator 116 is lessthan the height of the applicator shown in FIGS. 2B-4F and thus may beused in open surgical applications, for example.

Turning to FIGS. 7A-8F, a third example embodiment of a surgicalapplicator 116 and surgical clip 124 is shown from various perspectivesand cross-sections. At 706, 708, 710, and 712 various viewpoints of thethird example embodiment of a surgical clip 124 are shown. Inparticular, a front face view of an example clip 124 is shown at 706, aside view of clip 124 is shown at 708, a bottom view of clip 124 isshown at 710, and a perspective view of clip 124 is shown at 712. Inthis example, each of the first and second opposing sides 132 and 130 ofthe clip comprises a flat portion coupled via a curved top junction tothe top portion 128 and coupled via a curved bottom junction to the tip.For example, flat portion 751 is included in side 130 and flat portion753 is included in side 132. Each flat portion may be perpendicular tothe top portion 128 in the closed resting position; however, in the openposition of the clip, e.g., when the opposing sides of the clip aretemporarily bent outwardly during installation of the clip aroundeverted edges of tissue, an angle 791 between the flat portion and thetop portion may increase to an angle greater than 90°. Furthermore theteeth or barbs 260, 259, 262, and 261 included in the opposing tips 134and 136 may define a rounded rectangular aperture 263 in the bottom ofthe clip with two opposing parallel edges 751 and 753 separated by adistance, e.g., 1.25 mm, on respective tips 134 and 136.

Various views and cross-sections of the third example surgicalapplicator are shown at 702, 704, 714, 716, 718, 720, 722, and 724 inFIGS. 7B-8F. In particular, at 702, a perspective view of examplesurgical clip applicator 116 is shown. At 704, a detailed view is shownof a distal end 247 of the applicator 116 at the region A shown in view702. The view 704 is shown at a scale of 4:1 relative to the view shownat 702. At 714 a front view of applicator 116 is shown. At 716, adetailed view is shown of cross-section B-B shown in view 714. View 718shows a detailed view of the region C shown in view 716, where view 718is shown at a scale of 4:1 relative to view 716. View 720 shows a sideview of applicator 116. View 722 shows a cross-sectional view alongcross-section D-D from view 720. View 724 shows a detailed view ofregion E shown in view 722 and is shown at a scale of 4:1 relative toview 722. Further, the views 706, 708, 710, and 712 of clip 124 aredrawn at a scale of 8:1 relative to view 702 of applicator 116.

The example applicator shown in FIGS. 7B-8F is similar to the applicatorshown in FIGS. 5B-6F but has a height 242 greater than the height of theapplicator shown in FIGS. 5B-6F. For example, the height 242 ofapplicator 116 shown in FIGS. 7B-8F may be approximately 138 mm so thatthe applicator may be used during minimally invasive surgical proceduresto reach into small spaces to apply a surgical clip. Further, the flatportions of each surgical clip in the plurality of stacked surgicalclips 118 in this example form interfaces along opposing sides of thearray for interior walls of the clip applicator as shown in view 724.

Turning to FIGS. 9A-10F, a fourth example embodiment of a surgicalapplicator 116 and surgical clip 124 is shown from various perspectivesand cross-sections. At 906, 908, 910, and 912 various viewpoints of thefourth example embodiment of a surgical clip 124 are shown. Inparticular, a front face view of an example clip 124 is shown at 906, aside view of clip 124 is shown at 908, a bottom view of clip 124 isshown at 910, and a perspective view of clip 124 is shown at 912. Thesurgical clip shown in FIG. 9A is similar to the surgical clip shown inFIG. 7A. However, in this example, a thickness of the clip wall at theconcave top portion 128 is less than a thickness of the clip wall of theopposing sides 132 and 130. This example clip also includes flat regionson each of the opposing sides to assist in alignment of an array ofclips when included in a chamber of the applicator 116. Further, in thisexample, the teeth or barbs 260, 259, 262, and 261 included at theopposing tips of the clip do not converge to a point but insteadconverge to a flat edge. For example, a thickness and width of barb 260decreases in a direction towards the opposing barb 259 to a flat edgewith a length of 0.2 mm. The flat edge formed at the end of barb 260 isparallel to the flat edge formed at the end of the opposing barb 259.Further, the tapering barbs form an arc-shaped aperture adjacent to thefront and back faces of the clip. For example, the decreasing outerwidths of barbs 262 and 261 as they converge towards each other form anaperture defined by an arc 953 of a circle with a radius of 1 mmextending from the face of the clip into the interior of the clip at thetips.

Various views and cross-sections of the fourth example surgicalapplicator are shown at 902, 904, 914, 916, 918, 920, 922, and 924 inFIGS. 9B-10F. In particular, at 902, a perspective view of examplesurgical clip applicator 116 is shown. At 904, a detailed view is shownof a distal end 247 of the applicator 116 at the region A shown in view902. The view 904 is shown at a scale of 4:1 relative to the view shownat 902. At 914 a front view of applicator 116 is shown. At 916, adetailed view is shown of cross-section B-B shown in view 914. View 918shows a detailed view of the region C shown in view 916, where view 918is shown at a scale of 4:1 relative to view 916. View 920 shows a sideview of applicator 116. View 922 shows a cross-sectional view alongcross-section D-D from view 920. View 924 shows a detailed view ofregion E shown in view 922 and is shown at a scale of 4:1 relative toview 922. Further, the views 906, 908, 910, and 912 of clip 124 aredrawn at a scale of 6:1 relative to view 902 of applicator 116.

The applicator 116 shown in FIGS. 9B-10F is similar to the applicatorsshown in FIGS. 5B-6F and 7B-8F. However, in this example, the push rod243 does not include an extension element but instead comprises a rodwith a constant diameter and circumference throughout the length of therod. An end of the push rod 243 opposing the thumb pushing element is incontact with a top surface of a top clip in the array of stacked clips118. The end of the push rod in contact with the top portion of the topclip in the array 118 is shaped to conform to the concave shape of thetop portion of the clip in order to simulate the clip-on-clip contact ofclips in the array 118.

Turning to FIGS. 11A-12F, a fifth example embodiment of a surgicalapplicator 116 and surgical clip 124 is shown from various perspectivesand cross-sections. At 1106, 1108, 1110, and 1112 various viewpoints ofthe second example embodiment of a surgical clip 124 are shown. Inparticular, a front face view of an example clip 124 is shown at 1106, aside view of clip 124 is shown at 1108, a bottom view of clip 124 isshown at 1110, and a perspective view of clip 124 is shown at 1112. Thesurgical clip shown in FIG. 11A is similar to the surgical clip shown inFIG. 9A. However, in this example, the length 253 and width 299 aresubstantially the same, e.g., both the length 253 and width 299 may be 5mm and the top portion 128 includes an aperture 138. In this example,both the length 253 and the width 299 are greater than the height 254.Further, in this example, a size of the cut-outs 256 and 255 may belarger than previously shown, e.g., 2 mm. Further still, in thisexample, the barbs or teeth of the opposing tips define a centralrounded rectangular aperture 263 and two opposing circular apertures1151 and 1153 adjacent to the front and back faces of the clip andextending inwardly towards the center aperture 263. The larger cut-outsin the sides of the clips may permit wider opposing protrusions orgrippers 122 and 123 on the distal end 247 of the applicator 116. Theseprotrusions on the end of the applicator may bend inwardly from opposingsides of the applicator by a predetermined angle in order to engage thecut-outs in the clip. By enlarging the size of the cut-outs in the sidesof the clips, the angles at which the opposing protrusions on theapplicator bend inwardly may be decreased.

Various views and cross-sections of the fifth example surgicalapplicator are shown at 1102, 1104, 1114, 1116, 1118, 1120, 1122, and1124 in FIGS. 11B-12F. In particular, at 1102, a perspective view ofexample surgical clip applicator 116 is shown. At 1104, a detailed viewis shown of a distal end 247 of the applicator 116 at the region A shownin view 1102. The view 1104 is shown at a scale of 4:1 relative to theview shown at 1102. At 1114 a front view of applicator 116 is shown. At1116, a detailed view is shown of cross-section B-B shown in view 1114.View 1118 shows a detailed view of the region C shown in view 1116,where view 1118 is shown at a scale of 4:1 relative to view 1116. View1120 shows a side view of applicator 116. View 1122 shows across-sectional view along cross-section D-D from view 520. View 524shows a detailed view of region E shown in view 1122 and is shown at ascale of 4:1 relative to view 1122. Further, the views 1106, 1108, 1110,and 1112 of clip 124 are drawn at a scale of 6:1 relative to view 1102of applicator 116. As shown in view 1124, since the cut-outs in thesides of the clip in this example are larger, the opposing protrusionsor grippers 123 and 122 may be made longer so that they extend a greaterdistance into an interior of the chamber of the applicator for greaterstrength and engagement with the clip loaded at the distal end of theapplicator.

It will be appreciated that the configurations disclosed herein areexemplary in nature, and that these specific embodiments are not to beconsidered in a limiting sense, because numerous variations arepossible. The subject matter of the present disclosure includes allnovel and nonobvious combinations and subcombinations of the varioussystems and configurations, and other features, functions, and/orproperties disclosed herein.

The following claims particularly point out certain combinations andsubcombinations regarded as novel and nonobvious. These claims may referto “an” element or “a first” element or the equivalent thereof. Suchclaims should be understood to include incorporation of one or more suchelements, neither requiring nor excluding two or more such elements.Other combinations and subcombinations of the disclosed features,functions, elements, and/or properties may be claimed through amendmentof the present claims or through presentation of new claims in this or arelated application. Such claims, whether broader, narrower, equal, ordifferent in scope to the original claims, also are regarded as includedwithin the subject matter of the present disclosure.

What is claimed is:
 1. A surgical clip and surgical clip applicatorsystem, comprising: (a) the surgical clip applicator comprising: (i) abody having a first end and a second end; (ii) the first end havingfirst and second inwardly turned hooks; and (iii) a push rod insertableinto the second end, the push rod configured to apply pressure in thedirection toward the first end, and the pressure being applied to a topportion of the surgical clip; (b) the surgical clip, comprising: (i)first and second opposing sides extending from the top portion; (ii) thefirst side terminating at a first tip; and (iii) the second sideterminating at a second tip; (c) the inwardly turned hooks of the clipapplicator for respectively engaging the first and second sides; (d)while the inwardly turned hooks engage the sides, and in response to thepush rod applying the pressure to the top portion, the first and secondtips move away from each other; and (e) in response to the pressure fromthe push rod being released, the first and second tips move toward eachother.
 2. The system of claim 1, the first side having first hookengaging structure, the second side having second hook engagingstructure, wherein the inwardly turned hooks of the clip applicator arefor respectively engaging the first and second hook engaging structure.3. The system of claim 1, the first side having first hook engagingstructure, the second side having second hook engaging structure,wherein the inwardly turned hooks of the clip applicator respectivelydirectly engage the first and second hook engaging structure.
 4. Thesystem of claim 1, the first side having a first cut-out fullyencompassed by the first side, the second side having a second cut-outfully encompassed by the second side.
 5. The system of claim 1, thefirst side having a first tab positioned at least generally near thefirst side, the second side having a second tab positioned at leastgenerally near the second side.
 6. The system of claim 1, the first andsecond tips move away from each other such that the surgical clipreaches an open position.
 7. The system of claim 1, the first and secondtips move toward each other such that the surgical clip reaches a closedresting position.
 8. The system of claim 1, wherein while the first andsecond tips move away from each other, the first and second sides bendoutwardly away from each other to reversibly deform the surgical clipfrom a closed resting position to an open position.
 9. The system ofclaim 1, the surgical clip having a closed resting position in which thefirst and second tips have a first distance therebetween, and thesurgical clip having an open position in which the first and second tipshave a second distance therebetween, the second distance being longerthan the first distance; and
 10. A surgical clip and surgical clipapplicator system, comprising: (a) the surgical clip applicatorcomprising: (i) a body having a first end and a second end, the bodydefining a chamber between the first end and the second end, the chamberconfigured to house a plurality of the surgical clips arrayed in a stackof surgical clips with adjacent surgical clips in physical contact withone another; (ii) the first end having first and second inwardly turnedhooks; and (iii) a push rod insertable into the second end, the push rodconfigured to apply pressure in the direction toward the first end, andthe pressure being applied to a top portion of the surgical clip; (b)the surgical clip, comprising: (i) first and second opposing sidesextending from the top portion; (ii) the first side terminating at afirst tip; and (iii) the second side terminating at a second tip; (c)wherein when the stack of surgical clips is positioned within thechamber, the top portion of a top clip is configured to interface withthe push rod of the clip applicator and the first and second opposingsides of a bottom clip are configured to engage the inwardly turnedhooks of the clip applicator; and (d) while the inwardly turned hooksengage the sides of the bottom clip, and in response to the push rodapplying the pressure to the top portion of the top clip, the first andsecond tips of the bottom clip move away from each other; and (e) inresponse to the pressure from the push rod being released, the first andsecond tips of the bottom clip move toward each other.
 11. The system ofclaim 10, the first side of each surgical clip having first hookengaging structure, the second side of each surgical clip having secondhook engaging structure, wherein the inwardly turned hooks of the clipapplicator are for respectively engaging the first and second hookengaging structure.
 12. The system of claim 10, the first side of eachsurgical clip having first hook engaging structure, the second side ofeach surgical clip having second hook engaging structure, wherein theinwardly turned hooks of the clip applicator respectively directlyengage the first and second hook engaging structure.
 13. The system ofclaim 10, the first side of each surgical clip having a first cut-outfully encompassed by the first side, the second side of each surgicalclip having a second cut-out fully encompassed by the second side. 14.The system of claim 10, the first side of each surgical clip having afirst tab positioned at least generally near the first side, the secondside of each surgical clip having a second tab positioned at leastgenerally near the second side.
 15. The system of claim 10, the firstand second tips of the bottom clip move away from each other such thatthe surgical clip reaches an open position.
 16. The system of claim 10,the first and second tips of the bottom clip move toward each other suchthat the surgical clip reaches a closed resting position.
 17. The systemof claim 10, wherein while the first and second tips of the bottom clipmove away from each other, the first and second sides of the bottom clipbend outwardly away from each other to reversibly deform the surgicalclip from a closed resting position to an open position.
 18. The systemof claim 10, each surgical clip having a closed resting position inwhich the first and second tips have a first distance therebetween, andeach surgical clip having an open position in which the first and secondtips have a second distance therebetween, the second distance beinglonger than the first distance; and